Sheboygan Progressive Health Services

In the surveyor’s words

From the most serious findings on record at Sheboygan Progressive Health Services, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Jun 23, 2026

  Based on interview and record review, the facility failed to ensure 2 residents (R) (R1 and R2) of 7 sampled residents received care and treatment based upon comprehensive assessments and in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) after experiencing a change in condition.The day after an unwitnessed fall, R1 presented with a change of condition including increased pain, decreased appetite, reduced fluid intake, and decreased mobility. The facility did not ensure a nursing assessment was completed or notify R1's physician and Power of Attorney for Healthcare (POAHC) in a timely manner. R1's pain and decreased intake continued until they were transferred to the hospital 4 days after the fall. […]

• Immediate jeopardy, isolatedF580Oct 7, 2021

  Based on record review and staff interview, the facility did not ensure a physician was notified in a timely manner when 1 Resident (R2) of 1 resident experienced a significant change in condition. R2 was admitted to the facility following an episode of pancreatitis and was being monitored for an increased white blood cell count. On 9/11/21, CNA (Certified Nursing Assistant)-D reported stool came out of R2's vagina during peri-care. LPN (Licensed Practical Nurse)-C assessed R2 and stated stool came out of R2's vagina and rectum simultaneously. LPN-C faxed MD (Medical Doctor)-E; however, MD-E did not receive the fax and follow up was not completed. […]

• Actual harm, isolatedF689Jun 23, 2026

  Based on interview and record review, the facility did not ensure assistive devices to prevent accidents were implemented for 1 resident (R) (R1) of 3 residents from a total sample of 9 residents. R1 had an unwitnessed fall while self-transferring from wheelchair to toilet. Staff did not ensure R1's chair alarm was in place prior to the fall. R1 was transferred to the hospital and diagnosed with minimally displaced left lateral L2 and L3 (lumbar spine/lower back) transverse process fractures and a mild compression fracture of the T12 vertebral body (junction between the mid and lower back).Findings include:The facility's Fall Prevention and Management Guidelines policy, dated 7/18/24, indicates each resident will be assessed for fall risk and will receive care and services in accordance… […]

• Actual harm, isolatedF689Apr 5, 2023

  Based on staff interview and record review, the facility did not ensure 1 Resident (R) (R48) of 3 sampled residents reviewed for falls had adequate assistive devices and interventions in place to prevent accidents. R48 was at risk for falls. R48's care plan contained interventions for the assistance of one staff and a gait belt for transfers. R48 had a functional maintenance program (FMP) from therapy that was not given to nursing or incorporated in R48's plan of care. The FMP indicated R48 was to be transferred with a front wheeled walker in addition to a gait belt. R48 was transferred without a front wheeled walker and/or gait belt twice. R48 fell twice on R48's right leg below-the-knee post amputation surgical site and required two additional surgeries to close the site. […]

• No harm, potential for more than minimal, widespreadF812Jun 19, 2024

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a safe and sanitary manner. This practice had the potential to affect all 31 residents residing in the facility. Procedures for reheating food in a microwave were not followed. Cooling temperature logs were not completed for leftover and pre-made food. Cold food items were not maintained at a proper temperature during meal service. Staff did not complete appropriate hand hygiene during meal service. Findings include: On 6/17/24 at 9:47 AM, Surveyor conducted an initial tour of the kitchen. […]